Basic Information
| Provider Information | |||||||||
| NPI: | 1679552186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TERRELL | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3101 LATROBE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282114849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043767362 | ||||||||
| FaxNumber: | 7043761939 | ||||||||
| Practice Location | |||||||||
| Address1: | 8800 N TRYON ST | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282623300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043767362 | ||||||||
| FaxNumber: | 7043761939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 02/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 200100862 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 891295X | 05 | NC | MEDICAID | Q0086G | 05 | SC | MEDICAID |